Examining home visits from community health workers to help patients manage asthma symptoms
Secondary outcome measures included nights awakened due to asthma, asthma-related urgent care use (combining hospitalization, emergency department visits, and unscheduled clinic visits), β-agonist use, oral steroid use, and school days or workdays missed. Sources included a pre-post patient survey;...
| Main Authors: | , , , |
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| Corporate Author: | |
| Format: | eBook |
| Language: | English |
| Published: |
Washington, DC
Patient-Centered Outcomes Research Institute (PCORI)
2021, [2021]
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| Series: | Final research report
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| Online Access: | |
| Collection: | National Center for Biotechnology Information - Collection details see MPG.ReNa |
| Summary: | Secondary outcome measures included nights awakened due to asthma, asthma-related urgent care use (combining hospitalization, emergency department visits, and unscheduled clinic visits), β-agonist use, oral steroid use, and school days or workdays missed. Sources included a pre-post patient survey; home environmental checklist; and midpoint interviews with CHWs, clinic staff, and health plans. The results reported below were based on a multivariate model using all participants and across both intervention groups (ie, CHW and enhanced care). RESULTS: Our 551 participants with uncontrolled asthma included low-income patients aged 5 to 75 years. In total, 53% were adults, and 47% were children; 77% were non-White; and 88% were renters. There were 273 patients randomly assigned to receive CHW services and 278 who were not. BACKGROUND: A disproportionate burden of asthma is borne by racially and ethnically diverse groups with low income, disparities that are driven by social determinants of health. Little is known about the potential synergies between community health worker (CHW) home-visit services and planned, preventive asthma primary care visits (ie, enhanced clinical care). OBJECTIVES: Public Health--Seattle & King County, in partnership with local clinics, health plans, other asthma experts, and patients, reviewed existing asthma clinical guidelines for incorporation into community and clinical asthma health care interventions. We then assessed the effectiveness of a CHW home-visit protocol compared with usual care focused on low-income and racially and ethnically diverse groups with asthma. The intervention included a combination of quality-improvement tools delivered in a "change package" (ie, a group of specified preventive asthma health care elements, as described in detail in the Methods section) accompanied by training and support over the intervention period. An electronic health record (EHR) template focused on asthma guideline recommendations was developed and implemented to facilitate clinical decision support and interagency communication. For study participants assigned to both interventions (CHW and enhanced clinical care), efforts were made to coordinate care between the CHW and practice team, communicating through in-person meetings, phone conversations, and the EHR asthma template common management page once it was enabled. The purpose of the study was to assess the impact of the CHW intervention and the feasibility of coordinating this intervention with the clinical teams trained to provide enhanced, preventive asthma care. This trial was nested in a feasibility study of a planned preventive asthma "enhanced clinical care" intervention among a nonrandomly selected group of "safety-net" clinics, where attempts were made to coordinate the CHW's work with that of the clinical teams. This trial is known as Guidelines to Practice (G2P). METHODS: Participants were recruited over a 13-month period from 13 clinical sites, where patients were randomly assigned to receive CHW home-visit services or not. The participants were then followed for 12 months. The CHW intervention included 3 planned home visits covering asthma trigger reduction, education, self-management support, and goal setting. CHW services were provided in English, Spanish, or Somali. The enhanced clinical care intervention was implemented at 4 sites selected nonrandomly from the 13 sites. At each of these 4 sites, a "change team" was identified that consisted of a lead clinician and support staff. Evaluation of the feasibility study was impeded by the lack of reliable process measures from the clinical sites and delays in implementing the enhanced asthma health care intervention within the study time frame. We obtained results from qualitative interviews of the clinicians and support staff at the enhanced asthma health care sites and the medical directors from both involved federally qualified health center (FQHC) practice networks. Key themes expressed by the clinic teams and medical directors were a generally positive attitude toward the G2P and the enhancements in asthma care as a result of the enhanced asthma health care intervention, which are further elaborated in the Results section. CONCLUSIONS: We demonstrated statistically significant improvements across 8 health outcomes among patients randomly assigned to receive CHW services vs usual care. This represents a change in the original study design, which included assessing the health impact of the enhanced care intervention. Instead, we describe the enhanced care intervention as a feasibility study, which we decided upon for 2 main reasons: (1) The sample of enhanced care clinical teams was chosen nonrandomly, a change from the proposed randomized factorial design; and, (2) the full rollout of the preventive care processes that comprised the enhanced care intervention was incomplete at the end of the study timeline. Thus, we abandoned the original 2×2 factorial design and simply compared study participants randomly assigned to receive CHW home-visit services with those who were not randomly assigned to receive them. Primary outcome measures included self-reported asthma symptom-free days, Asthma Control Test (ACT) score, and Asthma-Related Quality of Life Questionnaire (AQLQ) score. There were 285 patients who received clinical care at 4 practices nonrandomly chosen to deliver enhanced asthma care and 266 patients who received care at 9 practices delivering usual asthma care. This resulted in 4 groups: group 1 (usual care) included 133 patients, group 2 (enhanced clinical care) included 145 patients, group 3 (usual care plus CHW intervention) included 133 patients, and group 4 (dual intervention: enhanced clinical care plus CHW) included 140 patients. There were statistically significant CHW intervention effects on all outcomes, including the primary outcomes of asthma symptom-free days (mean, 1.27-day improvement; 95% CI, 0.2-2.4), ACT score (1.2-unit improvement; 95% CI, 0.3-2.1), and AQLQ score (0.39-unit improvement; 95% CI, 0.2-0.6). However, the differences in ACT and AQLQ scores did not meet the published standards for the minimal clinically important difference (MCID) for asthma care. However, 2 of the 3 primary outcome measures, ACT and AQLQ scores, failed to meet the published MCID in this hard-to-reach population.63,64 Both care teams and CHWs reported that coordinating planned asthma care with the CHW's work was both feasible and acceptable. LIMITATIONS: The study had 9 main limitations: (1) The 4 enhanced clinical care intervention clinics were not chosen randomly. (2) The uptake of the clinic-based Planned Asthma Change Package by providers beyond the identified change team (ie, practice-wide spread) took longer than anticipated. The desired enhanced asthma health care changes continued to be implemented beyond the study intervention period at the 4 enhanced care sites as well as at the 9 usual care sites, which also received enhanced asthma health care training at the conclusion of the intervention period. (3) We have not been able to obtain valid care metrics from the EHR for closer inspection of care received by patients. (4) The 12-month end point CHW evaluation visit was, at times, difficult to complete within the study time frame, thereby introducing a potential seasonal bias to our outcome measures. (5) Most of the CHW staff had years of experience in delivering home visits, so our findings may not be generalizable to a newly hired CHW staff. (6) The CHW staff did most of the data collection, introducing potential bias in outcomes assessment. (7) There was relatively little communication between the CHWs and the enhanced care practice teams. (8) A nonrandomly chosen portion of patients receiving CHW services also received care at the 4 enhanced care practices, confounding the CHW intervention results. (9) We abandoned the results of the enhanced vs nonenhanced clinic groups because of the study design flaws |
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| Physical Description: | 1 PDF file (72 pages) illustrations |